1255856845 NPI number — MR. RYAN G WEAVER LO, ABOC, NCLEC

Table of content: MR. RYAN G WEAVER LO, ABOC, NCLEC (NPI 1255856845)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255856845 NPI number — MR. RYAN G WEAVER LO, ABOC, NCLEC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WEAVER
Provider First Name:
RYAN
Provider Middle Name:
G
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
LO, ABOC, NCLEC
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1255856845
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
625 SCHOOL ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PUTNAM
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06260-2424
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-630-4634
Provider Business Mailing Address Fax Number:
860-928-4975

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
625 SCHOOL ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PUTNAM
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06260-2424
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-630-4634
Provider Business Practice Location Address Fax Number:
860-928-4975
Provider Enumeration Date:
08/04/2017

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 156FX1800X , with the licence number:  1758 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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